Your Name:
Subject:
E-mail:

Address:
City:
State:
Zip Code:

Phone Number:

Please indicate if the following responses are submitted on behalf of either yourself or your child under the age of 18.
Self
My Child

What is your age (or the age of the child for whom you are filling the form out?
Age:

From birth until age 18 did you drink fluoridated city water for most of your water needs?
Yes
No

Do you have written records (check stubs, utility bills, etc) documenting your being a customer of your water utility / utilities that provided fluoridated water during your years 0 – 10 years old?
Yes
No

Did you consume well water during the period from 0 – 10 years old for any period more than three months?
Yes
No

Did you consume bottled water for any more than 20% of your water needs during the time from 0 – 10 years old?
Yes
No

As a child were you given prescription fluoride supplements (pill, drops, etc)?
Yes
No

If supplements were prescribed and taken, do you have medical records or other proof documenting the name of the physician, dentist, or other health professional that provided the fluoride supplements, the brand name of the supplements provided, and the length of time the supplements were taken?
Yes
No

Did your physician, dentist, or other health provider ask you detailed questions about your other possible sources of fluoride prior to prescribing the fluoride supplements?
Yes
No

Did you use fluoridated toothpaste during the years 0 – 10?
Yes
No

Do you have close-up photos of your teeth?
Yes
No

If you have photos of your teeth, you may submit them to fluoride@nidellaw.com. Two photos, no more than four, may be submitted, to include an in-focus, close-up of the teeth with the lips pulled back, showing only the lips and teeth, and a full-face-shot photo with teeth exposed. Examples of photos can be found below.

Minority populations in many cases ingest more fluorides than Caucasians, but persons of all races and ethnic backgrounds ingest fluorides and may be affected. If you would like to share your racial or ethnic background (not required), please check appropriate box:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
Caucasian/White
Other

Please Describe your Case:

NOTE: your filling out of this questionnaire and/or submittal of photos of a possible case of dental fluorosis is no guarantee, written or implied, of your receipt of any financial remuneration or settlement, nor of Nidel Law’s acceptance of your case. By your submission of photos and / or information on this questionnaire you hereby release to Nidel Law the rights to reproduce and distribute your teeth-shot photo(s) without your name attached as Nidel Law deems necessary in its investigation of a possible lawsuit on behalf of persons harmed by dental fluorosis and other fluoride-related injuries. Should it be determined that legal action is warranted, you will be asked for further documentation and be sent an appropriate retainer agreement.